A DRINK A DAY
WHEN it comes to drinking alcohol for medicinal purposes, most Americans get it wrong. Take a sampling of wine samplers at a recent tasting in Santa Barbara.
“I usually drink wine, but not every day,” says Mike White, 45. “Then one day a week, I go big -- maybe half to three-quarters of a bottle.” -- Wrong.
“I drink on the weekends only,” says Sophie Calvin, 40. -- That’s not it either.
“I have a glass of wine when I take a bubble bath,” says Mary Whitney, 40. “Every night.” -- Getting close, but it might be better if she also brought an entree into the tub.
“I have a glass of wine with dinner each night. I like the taste,” says Mark Biddeson, 52. “Or I’ll have a beer instead sometimes, depending on what I’m eating.” -- Bingo! He’s got it!
People drink to drown sorrows, celebrate victories, enhance a meal or loosen up with friends -- not necessarily to protect their hearts. Small wonder.
The folks who wag warning fingers over the dangers of trans fats, and hail the benefits of leafy greens, are silent on alcohol. These public health messengers -- who remind us to quit smoking, eat fresh fruits and vegetables and exercise every day -- are not about to tell people to start drinking.
Their reluctance comes even amid growing evidence that moderate drinking is beneficial. A study last week in the Archives of Internal Medicine showed that light to moderate alcohol consumption in people age 70 to 79 is associated with significantly lower rates of cardiac events and longer survival. A week earlier, researchers reported in the July 18 issue of the Journal of the American College of Cardiology that moderate alcohol consumption may help ward off development of heart failure.
Those studies join dozens of others showing that a drink a day for a woman, two for a man, is good for heart health. Studies from at least 20 countries in North America, Europe, Asia and Australia consistently show that moderate drinkers have rates of heart disease between 20% and 40% lower than abstainers or heavy drinkers, according to the National Institute on Alcohol Abuse and Alcoholism.
Other research is showing exactly how alcohol is beneficial -- and how to use it to best effect.
The guardians of public health aren’t ignoring these data. They know that for most people, alcohol can be good for the heart. But they also know that for others, it can be a health and social disaster.
Most doctors err on the side of caution, believing that the risk to the few outweighs the benefit to the many. They fear that some people encouraged to drink moderately will end up going too far.
And crossing the line from moderate to abusive drinking not only erases the heart health benefits, it introduces dozens of additional health problems. In the former Soviet Union and parts of Eastern Europe, for example, binge drinking was found to eliminate the rise in HDL, the cholesterol that protects the heart, seen in moderate drinkers, according to a 1998 study in the Journal of the Royal Society of Medicine. In a 2001 study in the International Journal of Epidemiology, weekend binge drinking in Lithuania was found to be responsible for spikes in the numbers of deaths from heart disease over the weekend.
“This is a true public health conundrum,” says Dr. Thomas Pearson, chairman of the department of community and preventive medicine at the University of Rochester School of Medicine. “If you really want to shift the alcohol balance toward the benefit, you’ll concentrate on responsible drinking among young people. It’s in the 45-plus-year-old where alcohol may be beneficial.”
Predicting who would be helped, who might be hurt, by adding a drink or two a day to the healthy-living formula is an age-related numbers game. In the United States, an estimated 100,000 excess deaths a year are attributed to alcohol, most of them in people younger than 45, according to the Centers for Disease Control and Prevention.
And an estimated 7% to 10% of Americans are alcoholics or abusive drinkers. They cannot drink moderately, and should not drink at all. Last year, the CDC ranked alcohol as the third-leading cause of preventable death in the country. Alcohol-related death and disability results from organ damage, brain damage and hemorrhagic stroke as well as injuries from accidents and violence. The estimated annual cost of alcohol abuse, including lost productivity, is $185 billion.
On the other hand, if current drinkers all suddenly quit, losing the protective benefits of alcohol, about 80,000 excess deaths would occur, most of them among people older than 45, according to a 1997 study by Pearson in the journal Circulation. That’s when people begin to hit the heart disease years.
“I’m personally of two minds,” says Dr. Kenneth Mukamal of Beth Israel Deaconess Medical Center in Boston, an author of the paper on alcohol and heart failure. “I’m a practicing primary-care doc. On the one hand, the observational evidence is quite strong and consistent that people who drink moderately and regularly have at least a lower risk of heart attack than people who don’t drink at all.”
But telling an adult in the habit of a drink or two after work, when there’s no plan to drive afterward, to continue the harmless habit is one thing. Telling a 21-year-old to start drinking daily is another.
He simply sees too many drinking disasters to risk a blanket recommendation.
Pearson adds: “Some of those people end up wrapping their cars around trees or end up drinking 20 beers a day.” Although no one knows if a hint at a recommendation for daily, moderate drinking would send increasing numbers of people on the road to alcoholism or alcohol abuse, doctors and public health experts have erred on the side of caution. It’s possible, some say, that adults who have always been teetotalers would start drinking and find out they like it a bit too much. Others might use the recommendation as an excuse to drink every day, kidding themselves about how much they are actually drinking.
Now, however, the benefits of alcohol are proving increasingly hard to ignore. A few researchers think that the evidence showing the benefits of moderate drinking is strong enough to start advocating moderate, regular drinking for mid-life adults who are responsible drinkers.
Lewis Perdue, author of “The French Paradox and Beyond,” a book about why people from France have lower rates of cardiovascular disease, looked at NIAAA’s numbers on the 20% to 40% reduction in rates of heart disease among moderate drinkers and did the math. “Proper knowledge and application of the scientific facts might save more than 200,000 people every year from dying of heart attacks,” he wrote.
Dr. Curtis Ellison, director of the Institute on Lifestyle and Health at Boston University School of Medicine, began examining links between moderate drinking and a protective cardiovascular effect in 1991. He agrees that it’s time to talk about the findings more openly.
“Nobody is saying that everyone should drink,” Ellison says. “But don’t withhold the evidence. Informed people make better choices. There is an intelligent way to drink -- small amounts every day. People aren’t stupid. They know when they’re drinking inappropriately.”
For most, the difference lies in when and how they drink. Daily, in moderation, in middle age seems to be the ticket.
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An effect on cholesterol
Alcohol, it’s thought, might keep clots from forming, arteries from constricting and platelets from becoming sticky.
The biggest proven benefit of moderate drinking is alcohol’s effect on cholesterol. Any alcoholic beverage slightly lowers LDL, the bad cholesterol. More important, it significantly raises HDL, the good cholesterol that protects against cardiovascular disease. In an evaluation of data from the National Heart Lung and Blood Institute Family Heart Study, Ellison found that moderate drinking raised protective HDL in middle-aged adults three to four times more than did exercise.
Some studies suggest that wine is better than other drinks at raising HDL because of its antioxidant properties. Grape juice also has those properties and has been shown to raise HDL, though someone would have to drink a quart of juice to get the same protection as from one serving of alcohol. But most researchers who have studied alcohol and heart disease believe the main benefits come from alcohol itself, in any form. “Red wine is not the only means by which you can get some of these antioxidants,” Pearson says. “I think it’s mostly the alcohol.”
Moderation and regularity of drinking seem to be key. “The vehicle doesn’t seem to particularly matter,” Mukamal says. “What matters is what beverage people consume regularly. In France it’s wine; in Germany, beer; in Japan, sake.”
Moderate drinkers may get a boost beyond raising HDL. Their blood is less likely to form clots than the blood of abstainers or heavy drinkers, and their bodies are better able to dissolve clots that appear. Clotting is, in part, a response to chemicals released from artery walls. In lab studies, exposure to alcohol diminishes the production of substances that promote clotting, and stimulates production of other substances that inhibit clotting.
The anti-clotting effect may be what argues most strongly for daily, sensible imbibing because after a day or so, the effect goes away. “Much of the protection for coronary heart disease seen in France is due to the fact that most French adults tend to consume some alcohol with their evening meal every day,” Ellison says. “Their clotting mechanisms remain in a favorable state all the time. The most recent data show that daily drinking is the healthiest.”
The benefit to moderate drinking comes with age. The new study on heart failure, for example, was aimed at elderly people because risk of the condition is high at their age. Fluid backs up in the lungs because the heart isn’t able to pump blood efficiently. Ankles swell and breathing becomes difficult.
Typically, such patients have been told to abstain from alcohol, largely because scientists knew that excessive drinking leads to the development of a heart that is oversized, flabby and not able to function properly -- the hallmarks of heart failure. If a lot of alcohol was very bad, the thinking went, a little would be a little bit bad.
But when Mukamal put it to the test by analyzing records of 5,595 Medicare recipients, he found that those who drank moderately, no more than 13 drinks a week, had a lower risk of heart failure.
It’s not clear why, but a potential explanation might be that alcohol directly lowers the pressure of blood in the lungs and prevents them from filling with fluid. For people on the verge of heart failure, the effect might be enough to prevent its onset, Mukamal says. The evidence isn’t strong enough to recommend a daily drink, he says, though physicians probably should stop automatically recommending abstention from alcohol for people with heart failure.
It’s uncertain whether drinking with food helps the heart, but combining alcohol and food slows down the former’s entry into the bloodstream, making it less likely a person will feel drunk.
But moderate drinking is not risk free. That anti-clotting effect could, in some, increase the risk of hemorrhagic stroke, or bleeding in the brain. And some studies show a relationship between moderate drinking and an increased risk of breast cancer, though results from the Nurse’s Health Study, a long-running study based at Harvard Medical School of more than 84,000 nurses, indicate that women who had adequate folate in their diet had no increased risk of breast cancer from moderate drinking.
Most concerning is that when a person crosses the line from moderate drinking to heavy drinking, the list of bad effects on the cardiovascular system is pretty much all-inclusive: increased risk of cardiomyopathy, high blood pressure, stroke and heart rhythm irregularities.
Most studies on heart disease and alcohol are long-term observational studies, including the Nurse’s Health Study and the Framingham Heart Study. Or they are laboratory studies of animals. A few human trials, lasting no more than six to eight weeks, have found favorable effects on blood cholesterol levels among moderate drinkers compared with abstainers.
But the gold standard of research, a randomized clinical trial comparing moderate drinkers with abstainers over a long period, is probably not possible.
“You’d have to find people who are willing to drink but also willing to be randomized not to drink,” says Mukamal. They’d have to hold that pattern for perhaps decades. Excluding alcoholics, problem drinkers or people who might develop those problems would also be difficult or impossible in a clinical trial. So the ultimate scientific proof of the benefits of alcohol is elusive.
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Cultural messages
The observational studies are building, but the public health conundrum remains. The cultural messages in America, Pearson says, are polarized and contradictory. “It’s either ‘Eat, drink and be merry,’ or ‘Devil rum,’ ” he says. Good health, for most people, lies somewhere in between.
“With alcohol, we’re still suffering a hangover from our fundamentalist Protestant roots,” Perdue says. “And we’ve got this nanny culture. Experts feel they know best and have the right to tell people what to do. We’ve got the idea that people don’t know how to deal with a mixed message.”
It’s not like that everywhere. A proposed study in Scotland, for example, was going to look at heart attack survivors, giving half the group a glass of wine daily, the other half a red-colored placebo.
“The doctors in Scotland said it was unethical to withhold red wine from heart attack survivors,” Ellison says. And in the United Kingdom, physicians recommend, unless people do not drink for personal health reasons including a history of alcoholism, that middle-aged and older men and postmenopausal women consider a drink or two a day for health.
Our own American Heart Assn. more guardedly recommends: “If you drink alcohol, do so in moderation.”
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Knowing the limit
Moderate drinking is defined as one drink a day for women, two for men. Here’s what that looks like in a glass:
Wine: 5 ounces
Beer: 12 ounces
Spirits: 1.5 ounces
